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  5. EWS - Preliminary Assessment Form (WL03)
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Exit Survey
 
 
Dear client,

Obesity is a life style disorder. Most probably the condition arises due to certain food habits, lack of exercise and stress. Obesity can be successfully managed by following healthy life style habits. In order to create an effective plan to manage the condition, we need to know and understand your current lifestyle habits.

Following questionnaire is designed to get an insight about your current habits pertaining to diet, exercise and stress. Take your own time to fill the form and make sure you provide most authentic and accurate data because your entire program will be designed based upon the details provided by you.
 
 
Basic Information
* First Name : 
* Last Name : 
Phone : 
Email Address : 
 
 
* Date of Birth:
 
 
* Gender
 
Male
 
Female
 
 
* Height (cm):
   
 
 
* Weight (Kg):
   
 
 
 
Medical Background
 
 
 
Are you suffering from (or earlier suffered from) Hyperthyroidism or Hypothyroidism?
 
Yes
 
No
 
 
 
Were you ever diagnosed with Hepatitis earlier
 
Yes
 
No
 
 
 
Which of the following symptoms you experience?
 
Sagging belly due to accumulation fat in lower abdominal area.
 
Round belly (Pot belly)
 
Acne
 
Weakness
 
Fatigue
 
Lethargy
 
Unable to sleep at night
 
Feeling sleepy in afternoon
 
Depression
 
Anxiety
 
Nervousness
 
Difficulty in getting up in the morning
 
Stress
 
Puffy eyes and face
 
Dark circles
 
Chest pain
 
High blood pressure
 
Craving for tea or coffee
 
Craving for Sugar
 
Frequent thirst despite drinking enough water
 
Gets out of breath while climbing stairs
 
Hair loss
 
Loose skin under upper arms
 
Joint pain
 
Bloating, burping or belching after eating
 
Constipation
 
Cravings for fried foods
 
Pain in right shoulder
 
Tongue coated with white film
 
Very dark urine in morning